Non–Q-Wave Infarction and Ostial Left Coronary Obstruction Due to Giant Lambl’s Excrescences of the Aortic Valve
A75-year-old woman presented with new onset of angina at rest associated with shortness of breath. The physical examination was significant for jugular venous distension and rales in both lungs. The chest radiogram showed bilateral lung congestion. She had ischemic ECG ST-segment and T-wave changes and serum creatine kinase-MB enzyme elevation consistent with a non–Q-wave myocardial infarction. Transthoracic echocardiography documented severe posterolateral and mild anteroseptal hypocontractility, with mild overall left ventricular function and mild aortic regurgitation. Because the symptoms were refractory to medical therapy, the patient was referred for cardiac catheterization. The coronary arteries appeared angiographically normal. However, the patient experienced severe chest pain at the end of the procedure. Repeat left coronary injection revealed a severe stenosis of the left main coronary artery, and the arterial blood pressure tracing was damped (Figure 1⇓); intracoronary nitroglycerin had no effect. The patient continued to have severe angina, worse ischemic ECG changes, and progressive bradycardia and hypotension, warranting placement of a perfusion balloon in the left main coronary artery and insertion of an intra-aortic balloon pump and a temporary pacemaker. She was referred for emergent open-heart surgery with the presumptive diagnosis of catheter-induced dissection of the left aortocoronary ostium.
Immediately after induction of anesthesia, a routine intraoperative transesophageal echocardiogram demonstrated a highly mobile round mass at the left coronary cusp of the aortic valve (Figure 2⇓). The mass appeared to obstruct the left coronary ostium in early diastole (Figure 2C⇓ and 2D⇓). The surgical approach was altered accordingly. Inspection showed a mass attached to the left coronary cusp of the aortic valve (Figure 3⇓); the left coronary ostium appeared normal. The patient underwent aortic valve replacement with a bioprosthetic valve, and no aortocoronary bypass grafts were required. Histological examination (Figure 4⇓) showed a papillary fibroelastoma of the aortic valve, also referred to as giant Lambl’s excrescences, fibroelastic hamartoma, or papilliferous tumor.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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